©2011-2018 Open Source Electronic Health Record Alliance
This work is licensed under a Creative Commons Attribution 3.0 Unported License
This work is licensed under a Creative Commons Attribution 3.0 Unported License
DVBCWAW1 ;ALB/CMM ARRHYTHMIAS WKS TEXT - 1 ; 5 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. Syncope, Stokes-Adams attacks - frequency?, precipitating factors?
;;
;;
;; 2. Other symptoms related to arrhythmia or its treatment.
;;
;;
;; 3. Current treatment, response, side effects.
;;
;;
;; 4. Describe the effects of the condition on the veteran's usual
;; occupation and daily activities.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Heart rate and rhythm.
;;
;;
;; 2. If arrhythmia is paroxysmal, what is frequency? Severity?
;; What are precipitating factors?
;;
;;
;; 3. Pacemaker present? If so, when inserted, effectiveness, side effects.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. EKG.
;; 2. Holter monitor, other tests as indicated.
;; 3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END